Tuesday, September 01, 2009. Reprinted with permission from ALN Europe™   The Case For A One Health Paradigm ShiftBy Bruce Kaplan, DVM and Mary Echols, DVM, MPHSeptember/October 2009 The One Health concept calls for a merging of perspectives from within human and veterinary medical disciplines. A public health emergency declared due to the newly emerged “swine flu” virus (H1N1) was recently classified as a worldwide pandemic. This is definitely an indication of impending similar, serious “brewing storms”. Since 1998, public health officials and scientists have been speculating about this with the avian flu (H5N1) virus strain. Fortunately, this has not evolved yet and may never do so. But, make no mistake; we are on the precipice of unpleasant health and health care threats that need to be addressed. These influenza events, plus the fact that approximately 75% of recently emerging infectious diseases affecting humans are diseases of animal origin, strongly suggest the need for a paradigm change on how public health approaches these phenomena called “zoonotic diseases”, i.e. diseases transmissible from animals to man. Today, many institutional, geographic, and financial barriers often prohibit meaningful interactions among experts. The result is that surveillance, research, prevention, and control measures for cross-species infections like influenza and dangerous bacteria emerging from antibiotic resistance, like those demonstrated by methicillin-resistant Staphylococcus aureus (MRSA) between pigs and people, have been short changed. This deficit must be rectified in order to pursue an enlightened course of modern health and health care for this generation and for generations to come. The 1918-1919 influenza pandemic killed 50 to 100 million people worldwide. Emerging influenza viruses have been isolated from a variety of animals, including humans, pigs, horses, wild and domestic birds, and sea mammals. The recent events caused by swine flu came to light only when human cases occurred. The interval between cross-species spread and the declaration of a public health emergency was extremely brief, a matter of days. It is reasonable to ask: could surveillance for the emergence of new strains of flu be more effective if targeted at animals—the “mixing pot” of flu virus evolution? Could we develop more effective tools to identify strains with potential to spill over from animals to humans? Besides influenza, other animal diseases are transmissible to humans. Hantaviruses exist in various rodent reservoirs where the hosts are persistently infected without disease symptoms. Specific hantaviruses transmitted from the contaminated urine and feces of infected rodents cause two important human diseases, hemorrhagic fever with renal syndrome (HFRS) and hantavirus-pulmonary syndrome (HPS). Nipah virus is a newly discovered virus of fruit bats responsible for encephalitis outbreaks in southeast Asia. West Nile, a virus of birds, invaded the U.S. in 1999 and is now endemic. Emerging bacterial disease agents can be transmitted by food animals including E. coli 0157:H7, various Salmonella species, Campylobacter species, and Streptococcus iniae (from farmed fish). Leptospirosis is the most common rat-transmitted disease in the United States. Combating zoonoses effectively will require a “One Health” approach—an interdisciplinary collaborative model for prevention and control of infectious disease epidemics, as well as chronic illnesses (e.g. cancer, obesity, orthopedic prosthetics, genetics, and others) that affect humans and animals. Physicians, veterinarians, ecologists, environmental scientists, laboratory animal specialists, and other health science-related disciplines must work together, equally without regard to “turf” barriers. ACHIEVEMENTS THROUGH INTEGRATION The One Health concept promotes the integration of human, animal, and environmental health by communication and collaboration among multiple disciplines. Successful One Health examples during the late 19th century and 20th century include: Yellow Fever - In 1893, Theobald Smith (physician) and Frederick L. Kilborne (veterinarian) published a seminal paper on Texas cattle fever transmitted by ticks that set the stage for Walter Reed’s discovery of yellow fever transmission via mosquitoes. Anthrax - In 1903, John McFadyean (veterinarian with a degree in veterinary medicine and medicine) published a paper on “McFadyean methylene-blue reaction in anthrax”, still referred to and recognized in microbiology texts.2,3 It is currently noted as “the ideal method for demonstration of the [anthrax] capsule.”4 McFadyean is regarded as the founder of modern veterinary research. Tuberculosis - In 1921, Albert Calmette (physician) and Jean-Marie Camille Guerin (veterinarian) collaborations resulted in the “BCG” Tuberculosis vaccine that, along with the use of streptomycin, was credited with a dramatic reduction in the human toll from Tuberculosis caused by Mycobacterium bovis contracted by contact from infected cattle. Immune System - In 1996, Rolf M. Zinkernagel (physician) and Peter C. Doherty (veterinarian) won the Nobel Prize for discovering how the body’s immune system distinguishes normal cells from virusinfected cells.5,6 ONE HEALTH COLLABORATIONS ADVANCE SCIENCEIn 1976, Frederick A. Murphy (veterinarian) and Karl M. Johnson (physician) worked closely together (along with others) to help unravel the mystery surrounding the initial outbreak of Ebola hemorrhagic fever and discovered its etiologic agent, Ebola virus5,6 Karl M. Johnson, MD is Past Director, Middle America Research Unit - NIAID, NIH Founding Chief -Special Pathogens Branch, CDC (retired). Commenting on their work together, Johnson noted, “Fred Murphy and I collaborated on zoonotic viruses, their pathogenesis, epidemiology, and ecology; initially at great distance but later in daily contact at CDC. Although Ebola virus was perhaps the most notable project, our work over many years truly exemplifies the concept of One World, One Medicine, One Health. “My prayer is that support, both scientific and financial, for the marriage of human and veterinary medicine will grow at an ever expanding rate. The earth requires it.” Fred Murphy, DVM, PhD, University of Texas Medical Branch, Department of Pathology, reflected on the work of some of the pioneers. He stated, “My recent delving into the foundations of medical and veterinary virology has provided much evidence of common roots and incredible early interplay, much more than we see today. For example, Walter Reed and his colleagues, the discoverers of the first human virus, yellow fever virus, acknowledged the influence of Friedrich Loeffler and Paul Frosch, who had discovered the first virus, foot-and-mouth disease virus, a few years earlier. “From my reading, it was Sir William Osler, the founder of modern human medicine and of veterinary pathology, who in the late 1800s coined the term ‘One Medicine’. Calvin Schwabe, the inspiring veterinary epidemiologist from UC Davis, has been credited with revitalizing the concept, and now it seems that the concept is gaining new breadth and depth, thanks to the efforts of the One Health Initiative. As others have noted, bringing substance to the concept, shaking up institutions and individuals, will require a difficult and long-term effort, especially as this applies to the interplay of physicians, veterinarians and biological scientists in biomedical research and in the scholarly base for public health—but, as [golfer] Arnold Palmer said, “Never up, never in.” In an impressive One Health example in the 21st century, veterinarian James “Jimi” Cook, DVM, PhD, a University of Missouri-Columbia college of veterinary medicine Professor of Orthopedic Surgery, and physician B. Sonny Bal, MD, JD, MBA, Associate Professor of Orthopedic Surgery college of medicine have been investigating practicable clinical medicine betterment in the field of orthopedics—for humans and animals. Drs. Cook and Bal have collaborated for about seven years on efforts to create hip and knee replacements without using commonplace biomechanical metal and plastic materials. The technique being developed by Cook for dogs involves use of laboratory grown tissue (cartilage) that can be molded into replicas of joints that require replacement. Bal and Cook are jointly developing a process whereby a similar process can be adapted for humans.7 Following a June 2009 story in the Missourian where both men were recognized for their important biomedical research, Dr. Bal commented, “Jimi Cook and I have worked alongside a team of specialists from medicine, veterinary medicine, and engineering for seven years now. Our current focus is to develop replacement joints that mimic the natural process of cartilage and bone formation as they grow and develop. This kind of collaboration is essential to the creation of better options for the replacement of failing hips and other joints. By working with specialists in the veterinary field, we are able to evaluate our technology more rapidly, and that means that we will be able to develop these alternatives for humans sooner than if we worked alone.” ONGOING EFFORTS The early 21st century physician and former President of the American Medical Association, Ronald Davis, MD [now deceased] collaborated with the former President of the American Veterinary Medical Association, Roger K. Mahr, DVM helping to establish a bond between the AMA and AVMA. Davis skillfully shepherded an historic One Health supportive resolution through to adoption by the AMA membership—a major milestone in the progress of this modern day One Health movement. In July 2007, Dr. Davis said, “Im delighted that the AMA House of Delegates has approved a resolution calling for increased collaboration between the human and veterinary medical communities and I look forward to seeing a stronger partnership between physicians and veterinarians. Emerging infectious diseases, with the threats of cross-species transmission and pandemics, represent one of many reasons why the human and veterinary medical professions must work more closely together”. A large number of North American professional organizations have endorsed the One Health concept. Among these are the American Medical Association; American Veterinary Medical Association; American Society for Tropical Medicine and Hygiene; Association of American Medical Colleges; and American Association of Veterinary Medical Colleges. Globally, One Health has been recognized by the Immuno Valley Consortium in The Netherlands; the Indian Veterinary Public Health Association; The Institute for Preventive Veterinary Medicine and Food Safety, Lazio and Tuscany Regions, Italy; the Italian Society of Preventive Medicine; the Corporation Red SPVet, Bogota, Colombia; and others. A recent One Health monograph—containing 13 diverse essays—was published in the European Journal, Veterinaria Italiana. It provides a strong scientific international case for implementing the One Health model worldwide. It is the product of 53 prominent interdisciplinary professionals (physicians, veterinarians, and health scientists) from twelve countries.1 CONCLUSIONThe One Health concept is a global strategy that is expanding within public health and academic circles. However, it is not widely known among practicing physicians, veterinarians, news media, or the general public. Once implemented, the synergism achieved will advance health care for the 21st century and beyond by accelerating biomedical research discoveries, enhancing public health efficacy, expeditiously expanding the scientific knowledge base, and improving medical education and clinical care. Seeking essential practicable “out of the box” scientific knowledge will most likely require a mind merging of various perspectives from within human and veterinary medical disciplines as well as others. References: 1.       Kaplan, Bruce, Laura H. Kahn, and Thomas P. Monath. One Health - One Medicine: linking human, animal and environmental health. Veterinaria Italiana Volume 45 (1)(2009) Web 2009/45_1/45_1.htm. 2.       Pattison, Ian. John Mcfaydyean: Founder of Modern Veterinary Research. London: J.A. Allen, 1981. Print. 3.       Dunlop, RH and DJ Williams. Veterinary Medicine: An Illustrated History. Mosby, 1996. Print. 4.       WHO Blood Safety and Technology: Manual for Laboratory Diagnosis of Anthrax. Last update: 27 April 2006. 5.       Kahn, LH, B. Kaplan, and JH Steele. Confronting zoonoses through closer colaboration between medicine and veterinary medicine. Veterinaria Italiana 43 (1)(2007) 5-19. Web. 43_1/5_19.pdf. 6.       Kahn, LH, B. Kaplan, and TP Monath. One Health in Action Series June 7, 2007. Online Posting. One Health/One Medicine. Web: 7.       7. Monath, Thomas P., Bruce Kaplan, Laura H. Kahn, and Jack Woodall. One Health Initiative. Dr. Bruce Kaplan, a retired veterinarian, is a former Centers for Disease Control and Prevention (USA) epidemiologist, practitioner of small animal medicine, United States Department of Agriculture-Food Safety Inspection Service public affairs specialist and staff officer in Washington, DC and a writer/editor/ columnist. Dr. Kaplan currently helps manage the One Health Initiative website and serves on the editorial board of the One Health Newsletter. Dr. Mary Echols, a public health veterinarian, is with the Palm Beach County Health Department, Palm Beach, Florida (USA). Dr. Echols is the Editor of the One Health Newsletter, a product of the Florida Department of Health, Division of Environmental Health and collaborates closely with the One Health Initiative website One Health team.,